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Patellofemoral Rehabilitation

Injuries In Football Conference

Stephen LaPlante PT, ATC

April 2017

Dallas, Texas

Disclosures

• Consultant for Incrediwear

Dallas, Texas Dallas, Texas

Objectives

• Discuss treatment strategies for acute and chronic

patellofemoral pain.

• Discuss the importance of a thorough assessment to determine

the most appropriate treatment strategy.

• Discuss general rehabilitation principles regarding patellar

rehab.

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Patellofemoral Pain

• Patellofemoral pain is a common source of anterior knee pain among young physically active populations.

• Affects 1 in 4 athletes, with more than 70% being between 16 and 25 years of age.

-Pappas et al. 2012

• Overall, 55.9% (95% CI, 50.8%-60.9%) of those reporting knee pain at baseline also reported pain 2 years later

– Adolescents diagnosed with PFP had a 1.26 (95% CI, 1.05-1.50) higher relative risk (RR) of knee pain at follow-up compared with other types of knee pain.

– Adolescents with PFP were significantly more likely to reduce or stop sports

participation compared with adolescents with other types of knee pain

-Rathleff et al. 2016

• No general consensus to the causes of patellofemoral pain

– No agreement on how PFP should be treated

- Powers 2003

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Patellofemoral Pain

Acute (Injury)

-Tramautic

-Direct blow to knee

-Patellar subluxation/dislocation.

-Fracture

Chronic (0veruse)

-Tendonitis/osis

-Bursitis

-”mal” patellar tracking

-tibial plateau stress fracture

-Chondromalacia

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Acute Injury

• Decrease inflammation and

pain

• Restore normal joint mobility/ROM

• Limit quadriceps atrophy

• Avoid open chain knee

extension

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Acute Injury

• Progressive loading

• Emphasize hip and core

strengthening early phase

• Restore symmetrical

movement patterns

• Gradual return to more sport

specific activities

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Chronic Patellofemoral Pain

• Mutifactorial

– Quadriceps flexibility

– Hamstring flexibility

– Gastroc/Soleus flexibility

– IT band flexibility

– Patellar Position

– Hypermobility of patella

– Hip Strength

– Core Stability

– Trunk Control

– Foot pronation

– Limited Ankle DF mobility

– Injury

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• For this reason, a proper

assessment needs to be

performed to determine the cause

• This includes looking at the

body as a whole

• Need to determine if it’s a

mobility or stability/motor

control problem or

combination of the two.

• Multiple assessment tools

available. Need to be

consistent and thorough.

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Patellofemoral pain

• The source of the pain (the knee) is not always the cause

– Source of sx’s may be intrinsic to the knee

– Cause of sx’s may be extrinsic to the knee

– These extrinsic factors may magnify a minor intrinsic

problem of the knee

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Assessment

• History

• Palpation

• ROM/mobility

• Strength testing

• Functional Testing

– Double leg squat

– Single leg squat

– Pain provoking tests

• Selective Functional Movement Assessment

• Functional Movement Screen

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• Pain provoking tests

– Patellar grind

– Patellar apprehension test

– Step up/down

– Jogging/Running

– Squatting

– Jumping

– Cutting

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Flexibility

• Witvrouw et al. concluded that decreased quadriceps and

gastrocnemius flexibility was significantly associated with

PFPS, HS flexibility was not.

• Patients with PFPS demonstrated significantly less flexibility of

the HS, quadriceps, gastrocnemius and soleus muscles

compared to healthy control subjects.

Piva et al., 2005

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• Decreased Quadriceps and Hip Flexor Mobility

– Leads to � patellofemoral stress

– Anterior pelvic tilt

– Limits HS activation

– Limits Gluteal Activation

Decreased mobility anterior-� inhibited posterior chain

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Hamstring tightness

• Leads to � patellofemoral stress 2° � knee flexion

• Limits knee extension and quadriceps activity

-Increased patellofemoral joint reaction forces

• Normal values

– 70 Active Straight Leg Raise

– 80 Passive Straight Leg Raise

*Need to make sure the Hamstrings are truly restricted.

– Is there an Anterior Pelvic Tilt?

– Is the posterior chain weak or inhibited?

– Might be “stretching out” their posterior “stability”

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Gastroc/Soleus Tightness

• Limited ankle DF mobility will

transfer up the kinetic chain

• Often see a toe out or

“pronated” foot

• Increased tibial IR to gain

additional ROM for terminal

stance phase of gait

• Increased knee valgus to compensate

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Calf Tightness (DF restriction)Treatment options

• “Voo Doo” bands neural

flossing

• Soft Tissue mobilization

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• Theorized that this may pull the patella laterally and increase

the stress over the patellofemoral joint

• No conclusive evidence to support this

-Piva et al., 2005

• What we do know

– Resists femoral adduction

– Associated with

• Genu varum

• Weak hip abductors

IT band restriction

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Strength

• Adductors

• Primarily adduct the hip,

but also assist in hip

flexion, extension and

rotation

• Direct attachment to the

MPFL

• Weakness or inhibition can lead to dysfunctional

tone/tightness

• This can lead to poor gluteal activation and

dysfunction

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Strength

• Patients with PFPS had significantly weaker hip external

rotators and abductors compared to control subjects.

Ireland et al. 2003

• Knee extension isometric strength as a predictor for PFPS

when normalized to body weight.

• Decreased muscle strength for knee flexion and hip abduction

were also associated with PFPS

-Boling, Am J sports med 2009

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Compared to controls, males and females with PFPS showed increased ipsilateral trunk lean, contralateral pelvic drop, hip adduction, and knee abduction during a single-leg squat.

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Dynamic Conceptual Modelfor PFPS

Boling et al. concluded that strengthening of the quadriceps and hamstrings along with teaching proper technique for performing dynamic

tasks are all components of an effective injury prevention program.

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Is the VMO the Issue?

• Lieb et al. -1968

– VMO fibers oriented at 55° from the longitudinal axis of the

femur.

– Primary restraint to lateral subluxation of the patella

– Insufficient balance of VL and VMO has long been

considered a contribution to developing PFPS.

– Suggested that the VMO was able to counterbalance the

pull of the much larger VL due to the discrepancy in mechanical advantages

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VMO/VL timing

• Cowan et al. found that subjects with PFPS have an imbalance

of timing between the VMO/VL.

• Chester et al. found that a trend was demonstrated towards a

delayed onset of VMO relative to VL in those with anterior knee

pain.

– But not all patients with AKP demonstrate VMO/VL

dysfunction

• McConnell and colleagues have shown that patella taping and

VMO strengthening through combined knee

adduction/extension is beneficial

– Evidence is inconsistent to support this

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9 different ex. Found that vastus medialis oblique muscle cannot

be significantly isolated during these exercises.

• No significant difference in VMO/VL EMG between control and PFPS.

– LaPrade 1998, Souza 1991, Cerny 1995, Boucher 1992

• EMG biofeedback to retrain the VMO is not supported in the

literature

-Collins 2012

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VMO Atrophy

• Theory is that the VMO atrophies more compared to the rest of

the quadriceps muscles following surgery.

• Giles et al. found atrophy of all portions of the quadriceps with

no selective atrophy of the VMO in subjects with PFPS

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VMO

• Can the VMO be isolated?

• During 22 exercises for

the quadriceps, VMO

activity was not higher

compared to VL Cerny 1995

• In a RCT, Song et al.

found no evidence that

the VMO can be isolated

• Grabiner et al. found that

it would take approx 60%

of MVC to stimulate VMO

hypertrophy

• When we are performing

“VMO strengthening” we are really working on the entire

quad.

• “No point to teach patients to

activate their VMO more during functional exercises as

patients do not use their

VMO less than healthy

individuals”

• Pattyn et al., 2012

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Q- Angle

• The relationship between PFPS and Q-angle has not been

consistent.

• A systematic review of prospective studies indicates that the Q-

angle is not a risk factor in PFP.

• Consensus statement from 3rd Int. Patellofemoral Pain Research

Retreat, 2013

• Typically taken statically. The contribution of abnormal

segmental motions and muscle activation may not be

appreciated during dynamic tasks.

• An increase in Q-angle can result in increased lateral facet

pressure as the patella is being forced against the lateral

femoral condyle.

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Biomechanics during landing

• Decreased peak knee flexion during landing as a predictor for

PFPS.

Boling et al. 2009

• Knee valgus moment at initial contact during landing was

predictive of PFPS.

Myer et al. 2010

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Rehabilitation Principles

•Weight bearing exercises have shown to be effective in short and long term outcomes in decreasing patellofemoral pain and enhancing cruciate ligament rehab and return to sport

•(Boling, et al., 2006; Heintjes, et al., 2003; Natri, et al., 1998; Witvrouw, et al., 2004; Witvrouw, et al., 2000; Shelbourne & Nitz, 1990)

•However, patellofemoral and tibiofemoral joint loading has been shown to vary according to exercise and technique variations.

•(Escamilla et al. 1998; Escamilla et al, 2001; Escamilla et al, 2008; Wilk et al., 1996

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• Patellofemoral force and stress increased with knee flexion, and was great in the wall squat exercises compared to the one leg squat between 50-90° knee flexion during the squat ascent

• There were no significant differences in patellofemoral force and stress between the two wall squat exercises

• A more functional knee flexion range between 0-50° may be appropriate during early phases of patellofemoral rehabilitation due to lower force and stress magnitudes compared to higher knee angles

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During lunging and squatting, excessive anterior knee translation (> 2-3 inches) beyond the toes should be discouraged due to higher patellofemoral loading

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Rehabilitation Principles

• Tri-planar

– Sagittal

– Frontal

– Transverse

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DNS Oblique Sit with Hip ER/IR DNS Oblique Sit with UE Reach

Oblique Sit “Tree Hugger”

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Single Leg Stance “hip drive” Single Leg Stance Controlled Pelvic Rotation

Single Leg Stance with Contralateral Row

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Split Stance Band Walks

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Split Stance Rotary Stability Medball Wall Toss

Tall Stance Rotary Stability Medball Wall Toss

½ Kneeling Rotary StabiltyMedball Wall Toss

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Conclusion

• Patellofemoral pain is multifactorial

• A thorough assessment needs to be performed.

• It’s important to not just focus on the knee.

• Need appropriate Hip and Trunk stability (not just glutes)

• Need to have normal ankle and hip mobility.

• Symmetrical Movements Patterns

• Progressive loading is critical to success.

• Return to sport will be based on individual characteristics as well as selecting the most appropriate treatment strategies.

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Thank You

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Bibliography

Abrams, G. D., J. D. Harris, A. K. Gupta, F. M. Mccormick, C. A. Bush-Joseph, N. N. Verma, B. J. Cole, and B. R. Bach. "Functional Performance Testing After Anterior Cruciate Ligament Reconstruction: A Systematic Review." Orthopaedic Journal of Sports Medicine 2.1 (2014): n. pag. Web.Barton, Christian, Vivek Balachandar, Simon Lack, and Dylan Morrissey. "Patellar Taping for Patellofemoral Pain: A Systematic Review and Meta-analysis to Evaluate Clinical Outcomes and Biomechanical Mechanisms." British Journal of Sports Medicine Br J Sports Med 48.6 (2013): 417-24. Web.Bennell, Kim, Margaret Duncan, Sallie Cowan, Jenny Mcconnell, Paul Hodges, and Kay Crossley. "Effects of Vastus Medialis Oblique Retraining versus General Quadriceps Strengthening on Vasti Onset." Medicine & Science in Sports & Exercise 42.5 (2010): 856-64. Web.Boling, M. C., D. A. Padua, S. W. Marshall, K. Guskiewicz, S. Pyne, and A. Beutler. "A Prospective Investigation of Biomechanical Risk Factors for Patellofemoral Pain Syndrome: The Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) Cohort." The American Journal of Sports Medicine 37.11 (2009): 2108-116. Web.Cerny, Kay. "Vastus Médiales Oblique/Vastus Lateralis Muscle Activity Ratios for Selected Exercises in Persons With and Without Patellofemoral Pain Syndrome." Physical Therapy 75.8 (1995): 672-83. Web.Chester, Rachel, Toby O. Smith, David Sweeting, John Dixon, Sarah Wood, and Fujian Song. "The Relative Timing of VMO and VL in the Aetiology of Anterior Knee Pain: A Systematic Review and Meta-analysis." BMC Musculoskeletal Disorders BMC Musculoskelet Disord 9.1 (2008): 64. Web.Cholewicki, Jacek, and James J. Vanvliet Iv. "Relative Contribution of Trunk Muscles to the Stability of the Lumbar Spine during Isometric Exertions." Clinical Biomechanics 17.2 (2002): 99-105. WebCowan, Sallie M., Kim L. Bennell, Kay M. Crossley, Paul W. Hodges, and Jenny Mcconnell. "Physical Therapy Alters Recruitment of the Vasti in Patellofemoral Pain Syndrome." Medicine & Science in Sports & Exercise 34.12 (2002): 1879-885. Web.Doxey, Gordon E. "Assessing Quadriceps Femoris Muscle Bulk With Girth Measurements in Subjects With Patellofemoral Pain." J OrthopSports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 9.5 (1987): 177-83. Web."The Effect of Patellar Taping on the Onset of Vastus Medialis Obliquus and Vastus Lateralis Activity in Persons with Patellofemoral Pain."

Manual Therapy 3.4 (1998): 223. Web.Edwin, Mirzabeigi, et al Isolation of the Vastus Medialis Oblique Muscle During Exercise. Am J Sports Med January 1999 vol. 27 no. 1 50-53

Escamilla, Rafael F. "Knee Biomechanics of the Dynamic Squat Exercise." Medicine and Science in Sports and Exercise (2001): 127-41. Web.Escamilla, Rafael F., Naiquan Zheng, Toran D. Macleod, W. Brent Edwards, Alan Hreljac, Glenn S. Fleisig, Kevin E. Wilk, Claude T. Moorman, and Rodney Imamura. "Patellofemoral Compressive Force and Stress during the Forward and Side Lunges with and without a Stride." Clinical Biomechanics 23.8 (2008): 1026-037. Web.Giles, Lachlan S., Kate E. Webster, Jodie A. Mcclelland, and Jill Cook. "Atrophy of the Quadriceps Is Not Isolated to the Vastus Medialis Oblique in Individuals With Patellofemoral Pain." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 45.8 (2015): 613-19. Web.Herrington, Lee. "The Difference in a Clinical Measure of Patella Lateral Position Between Patients with Patellofemoral Pain and Matched Controls." Journal of Orthopaedic and Sports Physical Therapy J Orthop Sports Phys Ther (2008): n. pag. Web.Laprade, Judi, Elsie Culham, and Brenda Brouwer. "Comparison of Five Isometric Exercises in the Recruitment of the Vastus Medialis Oblique in Persons With and Without Patellofemoral Pain Syndrome." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 27.3 (1998): 197-204. Web.Livingston, Lori A. "The Quadriceps Angle: A Review of the Literature." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 28.2 (1998): 105-09. Web. Dallas, Texas

Myer, Gregory D., Kevin R. Ford, Kim D. Barber Foss, Arlene Goodman, Adrick Ceasar, Mitchell J. Rauh, Jon G. Divine, and Timothy E. Hewett. "The Incidence and Potential Pathomechanics of Patellofemoral Pain in Female Athletes." Clinical Biomechanics 25.7 (2010): 700-07. Web.Ng, G.y.f., A.q. Zhang, and C.k. Li. "Biofeedback Exercise Improved the EMG Activity Ratio of the Medial and Lateral Vasti Muscles in Subjects with Patellofemoral Pain Syndrome." Journal of Electromyography and Kinesiology 18.1 (2008): 128-33. Web.Nakagawa, Theresa, Moriya, Erika, Maciel, Carlos, Serrao, Fabio. Trunk, Pelvis, Hip, and Knee Kinematics, Hip Strength, and Gluteal Muscle Activation During a Single-Leg Squat in Males and Females With and Without Patellofemoral Pain Syndrome. journal of orthopaedic & sports physical therapy, 42.6 (2012) 491-501Pappas, E., and W. M. Wong-Tom. "Prospective Predictors of Patellofemoral Pain Syndrome: A Systematic Review With Meta-analysis." Sports Health: A Multidisciplinary Approach 4.2 (2012): 115-20. Web.Pattyn, Els, Peter Verdonk, Adelheid Steyaert, Damien Van Tiggelen, and Erik Witvrouw. "Muscle Functional MRI to Evaluate Quadriceps Dysfunction in Patellofemoral Pain." Medicine & Science in Sports & Exercise 45.6 (2013): 1023-029. Web.Piva, Sara R., Edward A. Goodnite, and John D. Childs. "Strength Around the Hip and Flexibility of Soft Tissues in Individuals With and Without Patellofemoral Pain Syndrome." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 35.12 (2005): 793-801. Web.Piva, Sara R., Kelley Fitzgerald, James J. Irrgang, Scott Jones, Benjamin R. Hando, David A. Browder, and John D. Childs. "Reliability of Measures of Impairments Associated with Patellofemoral Pain Syndrome." BMC Musculoskeletal Disorders BMC Musculoskelet Disord 7.1 (2006): 33. Web.Powers, Christopher M. "The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective." J Orthop Sports Phys TherJournal of Orthopaedic & Sports Physical Therapy 40.2 (2010): 42-51. Web.Powers, Christopher M. "The Influence of Altered Lower-Extremity Kinematics on Patellofemoral Joint Dysfunction: A Theoretical Perspective." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 33.11 (2003): 639-46. Web.Powers, Christopher M., Samuel R. Ward, Michael Fredericson, Marc Guillet, and Frank G. Shellock. "Patellofemoral Kinematics During Weight-Bearing and Non-Weight-Bearing Knee Extension in Persons With Lateral Subluxation of the Patella: A Preliminary Study." J Orthop Sports PhysTher Journal of Orthopaedic & Sports Physical Therapy 33.11 (2003): 677-85. Web.Rathleff, M.S., Rathleff, C.R. Olessen, J.L., Rasmussen, S, Roos, E.M.. Is knee pain during adolescents self limiting condition. Prognosis of patellafemoral pain on other types of knee pain. Am J Sports Med. May; 44(5)2016.Rathleff, M. S., Rathleff c.R. K. M. Crossley, and C. J. Barton. "Is Hip Strength a Risk Factor for Patellofemoral Pain? A Systematic Review and Meta-analysis." British Journal of Sports Medicine 48.14 (2014): 1088. Web.Snyder, John. "Is VMO Training Truly the Gold Standard in PFPS Treatment? A Blog Article by John Snyder, DPT, CSCS." Is VMO Training Truly the Gold Standard in PFPS Treatment? Snyderphysicaltherapy, 13 Oct. 2015. Web. 04 Apr. 2016.Souza, Richard B., and Christopher M. Powers. "Differences in Hip Kinematics, Muscle Strength, and Muscle Activation Between Subjects With and Without Patellofemoral Pain." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 39.1 (2009): 12-19. Web.Tiberio, David. "The Effect of Excessive Subtalar Joint Pronation on Patellofemoral Mechanics: A Theoretical Model." J Orthop Sports Phys TherJournal of Orthopaedic & Sports Physical Therapy 9.4 (1987): 160-65. Web.Whittingham, Martin, Shea Palmer, and Fiona Macmillan. "Effects of Taping on Pain and Function in Patellofemoral Pain Syndrome: A Randomized Controlled Trial." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 34.9 (2004): 504-10. Web.Wilson, Tony, Nicholas Carter, and Gareth Thomas. "A Multicenter, Single-Masked Study of Medial, Neutral, and Lateral Patellar Taping in Individuals With Patellofemoral Pain Syndrome." J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 33.8 (2003): 437-48. Web.Witvrouw, E., D. Van Tiggelen, and Y. Thijs. "Intrinsic Risk Factors for Patellofemoral Pain Syndrome: Implications for Prevention and Treatment." Journal of Science and Medicine in Sport 14 (2011): n. pag. Web.Witvrouw, E., R. Lysens, J. Bellemans, D. Cambier, and G. Vanderstraeten. "Intrinsic Risk Factors for the Development of Anterior Knee Pain in an Athletic Population." AM J of Sports Med 28.4 (2000): 480-89. Web.Witvrouw, Erik, Claire Sneyers, Roeland Lysens, Jan Victor, and Johan Bellemans. "Reflex Response Times of Vastus Medialis Oblique and